The Effects of Quality Improvement for Depression in Primary Care at Nine Years: Results from a Randomized, Controlled Group‐Level Trial

Abstract

Objective. To examine 9‐year outcomes of implementation of short‐term quality improvement (QI) programs for depression in primary care. Data Sources. Depressed primary care patients from six U.S. health care organizations. Study Design. Group‐level, randomized controlled trial. Data Collection. Patients were randomly assigned to short‐term QI programs supporting education and resources for medication management (QI‐Meds) or access to evidence‐based psychotherapy (QI‐Therapy); and usual care (UC). Of 1,088 eligible patients, 805 (74 percent) completed 9‐year follow‐up; results were extrapolated to 1,269 initially enrolled and living. Outcomes were psychological well‐being (Mental Health Inventory, five‐item version [MHI5]), unmet need, services use, and intermediate outcomes. Principal Findings. At 9 years, there were no overall intervention status effects on MHI5 or unmet need (largest F (2,41)=2.34, p=.11), but relative to UC, QI‐Meds worsened MHI5, reduced effectiveness of coping and among whites lowered tangible social support (smallest t(42)=2.02, p=.05). The interventions reduced outpatient visits and increased perceived barriers to care among whites, but reduced attitudinal barriers due to racial discrimination and other factors among minorities (smallest F (2,41)=3.89, p=.03). Conclusions. Main intervention effects were over but the results suggest some unintended negative consequences at 9 years particularly for the medication‐resource intervention and shifts to greater perceived barriers among whites yet reduced attitudinal barriers among minorities.